Complaint·May 14, 2021

The allegation revealed the following: for allegation (Staff did not inform responsible party of injury.) It is being alleged that staff did not inform responsible party of her family member’s pressure injury. On 04/13/2021, LPA Jones interviewed the administrator Anna Miranda about the allegation. The administrator stated during the interview that she was made aware of R1’s pressure injury from hospice on March 25, 2021 which is the same day RP came to visit the resident. The administrator stated that she told RP about the injury during the visit. The administrator stated to LPA Jones that she did not see any pressure injuries on resident body from January 26, 2021 (resident’s admittance) to March 25, 2021 when hospice brought it to her attention. Staff 2 revealed to LPA during her interview that she observed pressure injuries on R1 but he had them already when he was admitted into the facility. Staff 2 stated that the injuries did not get worse and the status was about the same throughout the duration of R1 residing in the facility. Staff 3 stated that she observed something on R1’s left foot only. S3 stated that they called hospice and hospice started treating it. S3 Stated that the heel got better. Staff 4 stated that she was out of town but returned between February 10, 2021 and February 17, 2021 and she observed the wound on R1’s left heel only. S4 stated that the wound was being treated by her and hospice. S4 said she used a wound spray and wrapped the heel. S4 said hospice came every other day and hospice taught staff how to wrap the heel. Staff 5 revealed during her interview that she did not notice any wounds on R1 but did notice that R1 would push his foot on the mattress. S5 stated that staff would put pillows between S5’s feet. LPA interviewed Nellie from Anne Hospice who stated that on 03/18/21 the blistered was observed by another nurse and it was documented in her internal notes. Nellie stated that the wound was closed on R1's left heel. Nellie stated that the injury was not at any stage, but the nurse ordered heel protectors for R1 on 03/19/2021. Nellie stated that the wound opened on March 25, 2021. Nellie stated that the R1 was agitated and did not want nurses to touch him. Nellie stated that resident was repositioned, and pillows were placed between residents’ legs but resident would kick them. Nellie stated that she spoke with RP late March 2021 after the wound was open. Nellie stated that hospice tried to contact RP prior but was unable to speak with her. LPA interviewed nurse Angela from Bristol Hospice who started assisting R1 on April 6, 2021 after R1 moved from the facility. Angela revealed during her interview that R1 was admitted on April 6, 2021 and wounds were observed on both feet. Angela stated that April 15, 2021 the wound on the left heel were unstageable (Necrotic/necrosis wounds)due to the skin being dead. The nurse stated that the wound was on the left foot for a long period because the skin was black. The nurse stated that this type of injury does not occur in one week. LPA attempted to interview residents 1-5. Resident 1 stated that she is ok with living in the facility and she has never had an injury. LPA attempted to interview residents 2-5 and was unsuccessful due to communication barriers. LPA Jones reviewed R1’s hospice records. The records revealed that R1 developed white skin discoloration on R1's left heel turning into a blister on 03/18/21. R1’s left heel was in stage III on 03/24/21 and unstageable on 04/06/21. For allegation (Staff did not inform responsible party of missing medication.) It is being alleged that RP gave the facility a list of R1’s medication upon arrival and R1’s blood pressure medication was missing. LPA interviewed the administrator about the allegation. The administrator stated that she observed an empty bottle of the blood pressure medication, but she did not see the name of the blood pressure on the list when R1 was admitted into the facility. The administrator stated that the facility and hospice gave R1 all of the medication that was on the list when R1 was admitted. The administrator stated that she did not go over the list of medication that was brought over to Ladera Vista when R1 was admitted. The administrator stated that hospice changed the blood pressure order but LPA did not receive any documentation of the blood pressure order being changed. According to RP, the administrator advised her that hospice would be in charge of all of the medication and RP did not refill any of R1’s medication. Staff 2 revealed during her interview that she did not know what medication R1 was taking. Staff 3 stated that R1 was given blood pressure medication daily. Staff 4 stated that R1’s blood pressure was taken daily before R1 was given his medication. Staff 5 stated that she was not in charge of medication and she did not know what R1 was taking. Nellie from Ann Hospice revealed during her interview that hospice did not change R1's blood pressure medication order. Nellie stated that hospice gave R1 the medication that was on R1’s medication list that was provided to hospice from the administrator. Nellie from hospice stated that she did not see the medication Nifedipine 60mgs on R1’s list. LPA Jones observed a medication list provided by RP that showed R1 was supposed to be given Nifedipine 60mgs daily. LPA Jones observed another list provided from the facility and hospice and the medication Nifedipine 60mgs was not on the list. LPA attempted to interview residents 1-5 about the allegation. R1 stated that she is not aware of what medication she is taking. LPA was unsuccessful in interviewing resident 2-5 due to language barriers For allegation (Staff did not give medication as prescribed.) It is being alleged that R1 was taking a blood pressure medication called Nifedipine 60mgs -once a day in the morning and the facility did not administer the medication. The administrator Anna Miranda revealed during her interview that she only refilled the medication that was on the list provided when R1 was admitted. Staff 2 stated that she did not know what medication was given. Staff 3 and 4 stated that they gave R1 his blood pressure medication daily and staff 5 stated that she was not in charge of the medication. Resident 1 revealed during her interview that she is not aware of what medications she is taking and LPA was unsuccessful in interviewing R2-R5 due to language barriers. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted a copy of the report was given to administrator, Anna Miranda